patient self care program prev.ulcer

1. Prevention Of Diabetic Foot Ulcer
Disease A Patient Self Care Program
Dr. Vijay Viswanathan, M.D, Ph.D.,
Joint Director
Diabetes Research Centre
Chennai.

2. The diabetic patient is often divorced from
his feet, unable to see them because of poor
eyesight and unable to feel them.
[Bloom A. Clin. Endocrinal. Metab 1977].

3. Upto 50% of all non-traumatic lower
limb amputations are performed on
diabetic patients.
Most & Sinnock “Diabetes Care” 1983.

4. DIABETIC FOOT PROBLEMS
ARE A MAJOR CAUSE OF
HOSPITALISATION IN INDIA.
Sathe S.R. : Int. J. Diab. Dev. Countries 1994
Pendsey S : IDF bulletin 1993
V. Vijay et al IDF bulletin 1997

5. DIABETES MELLITUS
Autonomic
neuropathy
Somatic
neuropathy
(sensorimotor)
Peripheral
vascular disease
Neuroischaemic
ulcer
Neuropathic
ulcer
Decreased Altered blood
sweating flow
Limited joint
mobility
Cigarette smoking
dyslipidaemia
Small muscle wasting
Decreased pain &
proprioception
Ischaemic
ulcer
Pathways to foot ulceration in diabetic patients
Increased
foot
pressures
Psychological/behavioural
problems
Trauma
At risk
neuropathic
foot
Dry skin
Callus
Distended
foot veins:
warm foot
At risk
neuropathic
foot

6. Neuropathy Deformity Minor trauma
Baseline Pathophysiologic Environmental Time Ulceration
pathology involvement event
Accumulation of component causes
to form a sufficient cause
Completed
causal chain to
ulcer
The commonest causal pathway to incident diabetic foot ulcers.

7. Risk factors for development and progression of neuropathy and development of
neuropathic foot ulceration.
Risk factors for the development Risk factors for the development of
and progression of neuropathy of neuropathic foot ulceration
* Poor glycaemic control * Loss of pain sensation
* Undiscovered Type 2 diabetes * Undiscovered Type 2 diabetes
* Smoking * Smoking
* High alcohol intake * High alcohol intake
* Low socio-economic status * Low socio-economic status
* Renal failure. * Patient lives alone
* Lack of flexibility / suppleness
* Ill-fitting footwear
* Poor foot hygiene / footcare
* Denial of condition
* Lack of diabetes education
* History of previous ulceration or amputation
* Poor glycaemic control
* Peripheral vascular disease
* Decreased vibration sensitivity.

8. Staging of diabetic neuropathy
• Stage 0 :
No neuropathy (no symptoms and fewer than two
abnormalities on formal testing).
• Stage 1 :
Asymptomatic neuropathy (two or more abnormalities on
formal testing with no symptoms)
• Stage 2 :
Symptomatic neuropathy (two or more abnormalities on
formal testing with minor symptoms).
• Stage 3 :
Disabling neuropathy (two or more abnormalities on formal
testing with severe symptoms).

9. The Risk of Foot Ulceration in Diabetic Patients
with High Foot Pressure : A Prospective Study.
[A. Veves, H.J.Murray, M.J. Young and A.J.M.Boulton
Diabetologia, 1992.]
The Association Between Callus Formation, High
Pressures and Neuropathy in Diabetic Foot
Ulceration.
[ H.J.Murray, M.J. Young, S. Hollis, A.J.M.Boulton
Diabetic Med. 1996]

10. Mrs.Banamali Sahu

11. Peak Plantar Pressure in the study groups
Group 1 Group 2 Group 3 Group 4
n=40 n=123 n=118 n=26
Plantar Pressure 207 260* 347* 638*
K Pa (median) (100-441) (53-3274) (101-2942) (354-4484)
% with values above
median of controls - 63.4 79.7** 100
* P<0.02 Vs Group 1 by median test;
** P<0.008 Vs Group 2 by χ2 test.

12. Predictive factors for Recurrent Diabetic Foot
infection in South India.
Follow-up study of 374 patients who had undergone
surgery for foot infection during January 1994 and
December 1997.
[M:F 227:147; Mean age 54.9 + 9.4 yrs; Diabetes
duration 10.9 + 7.7 yrs].
Vijay Viswanathan, D.V.L Narasimham,
R.Seena, C. Snehalatha, A. Ramachandran,
Diabetic Medicine [2000]

13. Comparison of predisposing factors in relapsers and
non-relapsers.
Relapsers Non relapsers P value
n =198 n = 176
Age years 54.5 + 8.9 55.3 + 9.8
Smoking 33 (16.67 %) 31 (17.6 %)
Diabetes duration yrs 11.5 + 8.14 10.2 + 7.1
Mean base line
HbA1 % 10.3 + 1.1 10.4 + 1.1
Mean follow up
HbA1% 9.7 + 0.9 9.6 + 0.9
PVD** 49 (24.7%) 27 (15.3%) χ2=4.53 P<0.03*
Neuropathy** 134 (67.7%) 67 (38.0%) χ2=31.7 P<0.001*
* Significant
** Chi square test, all others were compared by the 't' test

14. Diabetic foot infection is a common cause for
hospital admission of diabetic patients in India.
Probable reasons
a. Socio-cultural practices such as bare foot walking.
b. Poor knowledge of foot care among diabetic patients.
c. Delayed referral of patients with foot infection to
specialists.
d. Inadequate facilities for diabetes care.
e. Poor socio-economic conditions.

15. Studies in Europe
Recurrence rate of 34% during a follow-up of 1 year and
70% over a period of 5 years.
Apelquist et al. J. Intern. Med..1993.

16. Routine foot examination : the first step
towards prevention of diabetic foot amputation.
Aim of the study
To determine the prevalence of common
foot problems among apparently healthy
diabetic patients.
Vijay Viswanathan et al.
Practical Diabetes International [2000].

17. PATIENTS AND METHODS :
Every third diabetic patient who came to the foot clinic
for routine testing of feet for neuropathy and PVD.
1010 patients (M:F - 706:304) were examined by the
foot educator.
Patients were examined for (i) Dry skin (ii) Heel
fissures (iii) Fungal nail infection (iv) Ingrowing toe
nails (v) Intertrigo (vii) Callus.
Dr. Vijay Viswanathan / DRC.

18. SMOKING x2
P
Yes No
(n = 288) (n = 722)
n % n %
Dry skin 238 82.6 540 74.8 6.73 0.009*
Heel fissures 166 57.6 432 59.8 0.33 0.57
Fungal nail infection 17 5.9 53 7.3 0.455 0.499
Ingrowing toe nail 25 8.7 47 6.5 1.155 0.28
Intertrigo 5 1.7 26 3.6 1.82 0.177
Callus 43 14.9 90 12.5 0.88 0.345
Neuropathy 75 26.0 128 17.7 8.35 0.003*
PVD 32 11.1 34 4.7 12.78 0.0003*
* Significant

19. Neuro Normal x2
P
(n = 165) (n=779)
n % n %
Dry skin 134(81.2) 591(75.9) 2.719 0.436
Heel fissures 99(60) 458(58.8) 1.802 0.614
Fungal nail infection 16(9.7) 48(6.2) 3.435 0.329
Ingrowing toe nail 33(20) 35(4.5) 52.27 0.0001*
Intertrigo 8(4.9) 19(2.4) 8.32 0.039*
Callus 46(27.9) 68(8.7) 67.67 0.0001*
COMPARISON OF PATIENTS WITH AND WITHOUT
NEUROPATHY

20. FOOTWEAR χ2
P
Always Outside
(n=113) (n=891)
n % n %
Dry skin 62 54.8 711 79.8 33.79 0.0001*
Heel fissures 45 39.8 549 61.6 18.82 0.0001*
Fungal nail infection 2 1.8 68 7.6 4.44 0.034*
Ingrowing toe nail 4 3.5 68 7.6 1.945 0.163
Tinea pedis 2 1.8 28 3.1 0.264 0.607
Callus 5 4.4 128 14.4 7.780 0.005*

21. Teaching patients how to practise foot care is widely
accepted as an important part of diabetes education
programs in order to prevent amputations.
Barth et al. “Diabetic Medicine” (1991).

22. Using Mirrors

23. What needs to be controlled
for foot at risk?
Metabolic control
Hyperglycemia
Hypertension
Hyperlipidaemia
Cessation of smoking

24. What needs to be controlled
for foot at risk?
Deformity
The importance of Callus removal in Neuropathic
Diabetic Foot - decrease plantar pressure
Dry skin and fissure management

25. What needs to be controlled
for foot at risk?
Debridement and ulcer management
Mechanical control
Off load, Off load, Off load
by rest, crutches, walkers, protective shoes, heel protective pad,
decrease plantar pressure by removal callus
The importance of callus removal in NFU
shows full dimension of the ulcer
deep swab possible
drainage of exudate, removal of dead tissue
Infection control
Education

26. • Learn to take good care of your feet.
• Practice what you learn every day.
• Foot problems must be detected and treated
properly.
• Take help of a Foot care specialist or your
Diabetes Care Team.
Need of the hour –Self care

27. Diabetes and your Feet
Why People with Diabetes require good
care of their Feet?
There are several reasons
• Loss of Sensation .
• Poor Circulation ( Slow Healing of wounds)
• Higher likelihood of developing foot infections that heal
slowly or improperly.

28. Self Foot Care
Recognize the Symptoms of Foot Problems
• Pay attention to peculiar sensations such as the feeling of
walking on Cotton or or on nuts.
• Beware of feeling of wearing tight socks even when the
feet are bare.
• Stabbing pain or burning sensations.
These all are major risk factors for the development
of serious foot problems.

29. Daily Foot Care
You can prevent major foot problems, if you can
• Inspect your feet daily
• Keep your feet clean and dry
• Trim your toenails carefully
• Protect you feet with appropriate footwear
• Have your doctor or nurse examine your
feet regularly (especially if you have any loss of
sensation in your feet or toes)

30. Daily Foot Care
Inspect your feet daily
• Examine your feet in good light after bath.
• Check for calluses, dry skin or areas that are reddened
• Check to see that the nails are well trimmed.
• Use a mirror to see the bottom of
and between the feet.
• Look and feel carefully for possible injuries, for breaks in
the skin, cuts, scratches, bruises, blisters, sores, and
discolouration.

31. Inspect your feet daily
Learn to recognize the early signs of Infection
• Unusual warmth over the injured area
• Redness
• Swelling
• Pain ( if you still have good Sensation)
• Drainage of pus from an opening in the skin.
If you find any of these immediately take Doctor’s
advice or ask your Diabetes Care team.

32. Keep your feet clean and dry
• Wash your feet everyday.Wash them as you wash your
hands, using soap and lukewarm water.
• Use a moisturising cream to add oil to your skin and keep
it smooth and soft.
• Dry your feet carefully after bathing, especially between
the toes where moisture can lead to a fungal infection.
• Use mirror, if required.

33. Trim your Toenails carefully
• It helps to avoid ingrown toenails, which can lead to
infection.
• Cut toenails after a bath, when soft and pliable.
• Cut your toenails straight across the top and not too far
back on the sides.
• Do not use a sharp instrument to clean under the nail, or
in the grooves.
• If your toe nails are too thick to cut, you can have them
cut by your Diabetes Care team.

34. Protect your feet with appropriate
footwear
Many foot problems can be avoided if you
are careful to protect your feet at all times
• Don’t walk barefoot.
• Choose Proper footwear of the correct shape and size.
• Always shop for shoes in the evening when the feet are the
largest.
• Check the size of the shoes wearing the thickest socks.
• Choose cotton or wool Socks.
• Socks should be free of wrinkles and holes.

35. Proper Footwear
• Shoe should be comfortable and fit well.
• Never wear Shoes which are too short or too narrow.
• Rounded toes give more space to the feet.
• Always choose flat shoes with thick, sturdy soles to protect the
feet from sharp objects.
• Leather shoes let the foot breathe freely.
• When buying a pair of Shoe, take in to account any bunions or
other irregularities. These will require wider and deeper shoe
to avoid pressure points.

36. Pressure Sores or Ulcers
• It starts with a callus, which is a sign of continuous
pressure or friction on a particular part of feet
• It is always advisable to treat the callus before an ulcer
occurs. See your Doctor or Diabetes Care Team
immediately.
• If not treated properly , such ulcers can lead to serious
foot problems like Gangrene.
• The presence of Gangrene can sometimes lead to the
removal of a toe or foot (Amputation).

37. Red marks on the foot

38. Cuts, and Injuries
• Keep the affected area or Injury clean and apply a sterile
bandage.
• If you have decreased sensation in your feet , you have to
be more careful to avoid Injuries such as minor accidents,
Burns etc.
• In absence of pain (alarm system), these minor injuries
may become serious and can lead to amputation or
removal of that part of the foot.

39. Fungal infection between the toes

40. Blisters and Cracks
• Never squeeze or puncture a blister.
• Proper bandage and Careful inspection is most important.
• If the blisters appears to contain blood or becomes
inflated see your doctor or Diabetes care team.
• Cracks are difficult to heal and Infections occur easily.
Daily use of foot cream to soften the skin as well as a
shock absorbing insole is recommended.

41. Blister on the foot

42. • It often caused by Improper nail trimming or
poorly fitted shoe.
• The problem can be solved by correcting the
footwear. You can ask you Diabetes Care Team
for assistance.
• As with all foot problems , prevention is the best
cure for ingrown nails.
Ingrown Nails

43. Inflamed toe

44. Corns and Calluses
• Usually Corns and calluses result from poorly
fitted footwear that puts pressure on certain area
of the Foot.
• A deep ulcer or crack can result if the callus is left
untreated.
• Consult your Doctor or Diabetes Care Team for
further treatment of Corns and calluses.

45. Callused skin

46. Nerve problems and Foot Care
• Nerve fibers carry messages between the brain and all
parts of the body.
• Nerve damage in your feet may lead to loss of sensations
and muscle weakness.
• It decreases your ability to sweat or impair blood flow to
your feet.
• It can affect the way you walk, leading to joint fractures
that occur without any apparent accident or other cause.

47. Symptoms of nerve problems in your
feet
• Tingling, or a feeling of “PINS and NEEDLES”.
• Numbness
• A peculiar feeling of walking on cotton or nuts.
• Stabbing or burning Pain.
• Pain with light touch of a bed sheet.
• A feeling like wearing tight stockings.
• Keeping your blood sugar as close as normal ( 90-
110 mg/dl) can slow the development of Nerve problems.

48. Who is at a risk of Foot Ulcers ?
Some People with Diabetes have a greater risk of
developing foot ulcers than others. The factors which
may play a role are:
• Those with more than 15 years of poorly controlled diabetes
• Impaired Vision
• Smoking

49. You should take more care of your feet if you
have any of the following
• Loss of sensation in your feet
• Poor Blood circulation as in pain at rest.
• Bunions or other foot deformities
• Previous foot ulcers
Who is at a risk of Foot Ulcers ?

50. Blood Sugar Control
• Poor blood sugar control is a risk factor for the
development of foot ulcers.
• Good control can prevent the development and
progression of nerve problems ( Loss of
Sensations).
• The better you blood control , the better your
body can take care for itself.

51. Poor Vision
• Poor vision puts your feet at risk, because you
may not be able to see the minor sores and other
foot problems at the bottom of the feet.
• Ask your diabetes care team for complete
inspection of the feet.

52. Smoking
• Do not smoke as nicotine causes blood vessels to
shrinks and slows down the blood flow to the
foot.
• Impaired blood circulation can increase the foot
Problems.

53. Examination of your feet
• Assess the general condition of your skin and nails
• Check for signs of poor circulation.
– Cold extremities, absent or weak pulsations
• Check if you can feel normal sensations.
• Look for the deformities such as bunions.
• Note any calluses.
• Check for signs of infection, injury and ulcers.
• Watch the way you walk and note any changes.

54. Tests Done On Feet
• For the loss of protective sensation like pain.
• Your ability to feel vibration.
• Light touch with a monofilament.
• For impaired blood circulation, or foot pulses.
• Toe blood pressure.
• An angiogram of arteries if required.

55. Foot at risk - 1
• Our job – look after “NDF at risk”
• A: Preventive measures
• Treatment - rapid and intensive
• Rest
• Off load
• Antibiotics
• Foot wear
• Patient education